Should the Purchase and Sale of Organs for Transplant Surgery be Permitted? BECKER

There were about 50,000 persons on the waiting list for kidney transplants in the United States in the year 2000, but only about 15,000 kidney transplant operations were performed. This implies an average wait of almost four years before a person on the waiting list could receive a kidney transplant. The cumulative gap between demand and supply for livers was over 10,000, which implies an average wait for a liver transplant of a couple of years. In 2000, almost 3000 persons died while waiting for a kidney transplant, and half that number died while waiting for a liver transplant. Many also died in other countries while on the queue waiting for an organ transplant. Some of these people would have died anyway from other causes, but there is little doubt that most died too early because they were unable to replace their defective organs quickly enough. If altruism were sufficiently powerful, the supply of organs would be large enough to satisfy demand, and there would be no need to change the present system. But this is not the case in any country that does a significant number of transplants. While the per capita number of organs donated has grown over time, demand has grown even faster. As a result, the length of the queue for organ transplants has grown significantly over time in most countries, despite exhortations and other attempts to encourage greater giving of organs. In recent years the US has taken several steps to improve the allocation of available organs among those needing them, such as giving greater priority to those who could benefit the most. These steps have helped, but they have not stopped the queues from growing, nor prevented large numbers of persons from dying while waiting for transplants. Some countries use an "opt out" system for organs, which means that cadaveric organs can be used for transplants unless persons who died had indicated that they did not want their organs to be so used. A PhD thesis in progress by Sebastien Gay at Chicago shows that opt out systems may yield somewhat more organs for transplants than the "opt in" systems used by the US and many other nations, but they do not eliminate the long queues for transplants. To an economist, the major reason for the imbalance between demand and supply of organs is that the United States and practically all other countries forbid the purchase and sale of organs. This means that under present laws, people give their organs to be used after they die, or with kidneys and livers also while they are alive, only out of altruism and similar motives. In fact, practically all transplants of kidneys and livers with live donors are from one family member to another member. With live liver transplants, only a portion of the liver of a donor is use, and this grows over time in the donee, while the remaining portion regenerates over time in the donor. If laws were changed so that organs could be purchased and sold, some people would give not out of altruism, but for the financial gain. The result would be an increased supply of organs. In a free market, the prices of organs for transplants would settle at the levels that would eliminate the excess demand for each type of organ. In a paper on the potential of markets for live organ donations, Julio Elias of the University of Buffalo and I estimate that the going price for live transplants would be about $15,000 for kidneys and about $35,000 for livers. We recognize, however, that the data are too limited to be confident that these numbers would be close to equilibrium prices that equate supply and demand-they may be too high or too low. But even if our estimates were only half the actual equilibrium prices, the effect on the total cost of transplants would not be huge since current costs for live transplants in the US are in the range of $100,000 for kidney transplants and $175,000 for liver transplants. An open market in organs would sharply curtail the present black market where some persons in need of transplants have them in poorer countries like Turkey where enforcement against selling organs is slack. Since the quality of the surgeons and hospitals in these countries is much lower than in advanced countries, this often greatly reduces the quality of the organs used and how well they are matched to the organ types of recipients. Still, despite these strong arguments in favor of allowing commercial markets in organs, I do not expect such markets to be permitted any time in the near future because the opposition is fierce. Some critics simply dismiss organ markets as immoral "commodification" of body parts. More thoughtful critics suggest that allowing organs to be bought and sold might actually reduce the total number of organs available for transplants because they claim it would sufficiently lower the number of organs donated from altruistic motives to dominate the increase due to those sold commercially. That scenario, however, is extremely unlikely since presently only a small fraction of potentially useable organs are available for transplants. Compensating persons either for allowing their organs to be used after their death, or for kidneys and livers to be used while they are alive, would enormously widen the scope of the potential organ market. Another set of critics agree with me that the effect on the total supply of organs from allowing them to be purchased and sold would be large and positive, but they object to markets because of a belief that the commercially-motivated part of the organ supply would mainly come from the poor. In effect, they believe the poor would be induced to sell their organs to the middle classes and the rich. It is hard to see any reasons to complain if organs of poor persons were sold with their permission after they died, and the proceeds went as bequests to their parents or children. The complaints would be louder if, for example, mainly poor persons sold one of their kidneys for live kidney transplants, but why would poor donors be better off if this option were taken away from them? If so desired, a quota could be placed on the fraction of organs that could be supplied by persons with incomes below a certain level, but would that improve the welfare of poor persons? Moreover, it is far from certain that a dominant fraction of the organs would come from the poor in a free market. Many of the organs used for live liver or kidney transplants are still likely to be supplied by relatives. In addition, many middle class persons would be willing to have their organs sold after they died if the proceeds went to children, parents, and other relatives. Although this is not an exact analogy, predictions that a voluntary army would be filled mainly with poor persons have turned out to be wrong. Many of the poor do not have the education and other qualifications to be acceptable to the armed forces. In the same way, many poor persons in the US would have organs that would not be acceptable in a market system because of organ damage due to drug use or various diseases. Still another criticism of markets in organs is that people would be kidnapped for their organs, and that totalitarian governments would sell organs of prisoners. This would happen, but not likely on a significant scale since the source of organs offered for sale could be determined in most cases without great difficulty. A criticism particularly of a commercial market for live transplants is that some persons would act impulsively out of short run financial needs, and that they would regret their decision to sell a kidney or allow their liver to be used for a transplant if they had taken more time. I do not know how important such impulsive behavior would be, but it could be sharply reduced by having a month or longer cooling off waiting period between the time someone agrees to supply an organ and the time it can be used. They would be allowed to change their mind during the interim. Many of the arguments against the sale of organs indirectly stem from an influential book in 1971by the British social scientist Richard Titmuss, The Gift Relationship: From Human Blood to Social Policy. He argues against allowing blood to be sold for transfusions, and compares the British system, which did not allow the purchase of blood, with the American system, which did allow its purchase. Titmuss basically ignored that the American system in fact was getting more blood per capita than the British system. Instead, he concentrated on the quality of the blood. Since a significant fraction of the American blood came from individuals with hepatitis and other diseases that could not be screened out, the blood given under the British system tended to be healthier. In the absence of effective screening techniques, perhaps shutting down the commercial market was an effective way then to improve blood quality. But that is no longer the case as highly effective methods have since been developed to determine whether blood is contaminated with various types of hepatitis, the HIV virus, and other transmittable diseases. Under present screening technology, a market in blood yields much more blood, and with enough diligence its quality can be maintained at a high level. My conclusion is that markets in organs are the best available way to enable persons with defective organs to get transplants much more quickly than under the present system. I do not find compelling the arguments against allowing the sale of organs, especially when weighed against the number of lives that would be saved by the increased supply stimulated by financial incentives.

Comments

[andrew]

there's also a shortage of cadavers for medical research in England and Florida:

u.k.
http://www.guardian.co.uk/medicine/story/0,11381,1635620,00.html

florida:
http://www.gainesville.com/apps/pbcs.dll/article?AID=/20051213/LOCAL/51212039/1078/news

body donation programs in the u.s.:
http://www.med.ufl.edu/anatbd/usprograms.html

the chinese "recycle" organs from condemmed inmates:
http://ethics.tamucc.edu/article.pl?sid=05/11/19/0044254

I also read somewhere China is providing bodies to U.S. medical schools, but I can't seem to find the link. Anyway, enjoyed the post.

peace,
A

[EH]

Mr. Becker's argument seems cogent.
The worry about "commoditzation" and "exploiting the poor" betoken, I think, a total misunderstanding of the issue AND the CURRENT reality, in which a) there is a growing demand of organs, b) there is thus (and for other reasons) a diminishing supply, and c) exploitation is part and parcel to a "free" market system: it is part of, that is, making commodities out of "ordinary" things (as if there were such entities)=commodisation.
If the poor are exploited with this opening of the market, then they are REALLY being exploited now, with everything else. And I reject such patently illogical (marxist) claptrap. you can analyse "abuse" into any situation. the truth is, the immodest proposal is not unconstitutional.

Once the system is legalized, it'll be argued, crime wll not abate, (as with loosening gun control): on the contrary, just as blood HIV transfusion people have incentives to get money despite the horrible crime they commit (or neglect the money, and are evil, sick villains--probably few, relatively), poor people who shouldn't will succumb for want of lucre to put themselves and other in danger.
The argument, however, could be made for proscribing suicide (whcih, apparently, it stupidly is): protect the individual (and society) from his own will-power.
Both are incoherent positions. In the Liberal Age, and in a country that believes in Rights, an individual must be entrusted wiith knowing--and indeed FORCED to know (law is the best way to reflect the demand society imposes for this, I think Aristotle discovered that)--, on the most basic levels (I'm not talkiing about tobacco/cigarette poisoning) about the consequences of his actions. They;'re already offering prisoners benefits for organ donations in some countries.
I recommend a trial run on this. And I'm a libertarian/conservative.

[nate]

"Still another criticism of markets in organs is that people would be kidnapped for their organs, and that totalitarian governments would sell organs of prisoners. This would happen, but not likely on a significant scale since the source of organs offered for sale could be determined in most cases without great difficulty."

Per my fuzzy recollection, years ago in a class I asked a tax professor a hypothetical question about deducting a loss on one's taxes if one had an organ stolen. Per my fuzzy recollection, the professor said there could be no loss deduction because the basis in the organ was $0.

The tax ramifications of this are interesting. Would the seller pay tax on the proceeds from selling his liver or kidney? Would the seller pay tax at the capital gains or ordinary income tax rate? If capital gains, what is the cost basis in the organ? If someone donated an organ, would the donor be allowed a tax deduction for a charitable gift?

More people than one might expect may fear organ stealing. Some of it may be fear and not based on fact or reality - I do not know. More research or information on a black market for organs, if any exists, would be interesting.

[Joe Merchant]

Science Fiction author Larry Niven had an interesting take on the future of organ transplantation: something to the effect that demand for organs was so great that the government imposed organ donation as a penalty for recidivist misdemeanor criminals (such as: running three red lights in a single year...) I never did like reading his works with heavy influence from "The State", it didn't feel like a fun place to live.

Recently, an enterprising young Texan in need of a transplant conducted an extensive, and costly, ad campaign for a donation - it worked for him. If you're dying, you really don't have much to lose, even if the world thinks your billboards are in bad taste.

In today's world, the super-rich have access to whatever organ transplant needs they might want to fill. They may have to relocate to countries where donations are legal, but with enough money, you can hire good doctors to do a trans-oceanic housecall. Organ procurement can be costly in some cases, but don't believe that it's impossible.

Comoditization of the organ market would increase timely access for the next few stratum of wealthy below the super-rich. I think it would be a good thing, but I wouldn't want my insurance premiums to increase to cover the cost of the benefits (which Posner argues would be negligible, on the order of 10% of the total operation, but this ignores the follow-on costs of keeping the transplanted Frankenstein alive after the operation.....)

[ajtall]

Professor Becker,

Regarding the argument that allowing a market might lead to more kidnappings, this sounds somewhat analagous to kidnappings (and killings) of pregnant women for their babies. It rarely happens. On the other hand, it seems many doctors are more concerned with preserving organs of dying patients (during emergency situations, for example) than with actually trying to save the patient. This is one reason I didn't check "organ donor" on my drivers license. Have you any data on this?

[Harry Clarke]

A grotesque and glib market-is-always-right argument. There are a myriad of principal/agent issues that suggest this view is simplistic. Are the trades voluntary and what sorts of incentives will drive alternative treatment technologies if you can readily rely on a down-and-out human desparate for cash? Oh yes, and let us dismiss the counterargument that you are making this desparate person worse off by denying him or her the opportunity to trade. Its wrong because people make bad judgements and can be coerced. Its also wrong because it reduces morality to individualistic utilitarianism which is one approach to human life not a law of nature.

What's happening to thinking in US economics? What is it so homogenised? What is economics becoming a pervasive free market ideology that essentially vulgarises Adam Smith but isn't backed up by modern theory? I looked today at the program for the January AEA meetings and the apparent uniformity of offerings is just sad. But the repetitive theme is reproduced in this post.

[Arun Khanna]

Professor Becker is correct in his assumption that free markets in human organs are unlikely to be legalized. I suspect this issue will be solved in the future by stem cell research leading to the ability to 'grow' human organs from organ cells.

[Lab_FROG]

The "commoditization" counter-argument seems to be a form of negative externality. Those stopping the creation of a legal market for human organs get good feelings in supporting their belief in a mystical value of human life, while facing only a fraction of the cost (the probability that they will need an organ).

Regardless, as the market is unlikely to be legalized, an alternative is for the opt-out system to be used and those who choose to opt-out (within ten years of when they go on a waiting list) cannot get a donated organ unless the supply becomes greater than the demand (unlikely).

Frog has also heard that a way to get moved up a waiting list to make a donation to the hospital. The hospital then perceives the person to be more likely to benefit from the transplant. Anyone have a source for this beyond hearsay?

[Yong]

"In the same way, many poor persons in the US would have organs that would not be acceptable in a market system because of organ damage due to drug use or various diseases."

"poor persons in the US" could be perfectly healthy persons from poor countries who are in the U.S. to sell their organs, perhaps on tourist visas paid for by doctors or their agents. The cost of paying such poor and healthy donors to travel to the U.S. is nothing compared to the handsome fees that would be earned by the doctors or their agents. Even more likely would be for some country or region, say Hongkong, which is close to populous and poor countries and in which a reasonable medical infrastructure is already in existence, to become a world center for organ selling and purchasing. Donors and donees would travel to such world centers to complete the transaction. Organs could be listed on E-Bay together with information that are relevant to the conditions of the organs such as the diet, age, weight and height of the donors for the donees to bid up or down the going price. The inevitable result: systematic and discriminatory exploitation of citizens of one country by another. Sounds like a capitalist hell to me.

[David J. Undis]

A legal non-monetary market for organs exists in the United States. It's called LifeSharers. Anyone can participate for free at http://www.lifesharers.org.

When you join LifeSharers you agree to donate your organs when you die, and you also agree to offer them first to fellow members. In return you get preferred access to the organs of all other members.

This is an excellent trade. By giving up your organs after you can't use them anymore, you increase your chances of getting an organ if you ever need one. Given that more than half of the people who need a transplant die before they get one, this is a significant benefit.

By creating a pool of organs available first to members, LifeSharers creates an incentive for non-donors to donate and to join LifeSharers. This incentive gets more powerful as the number of members increases.

LifeSharers uses a form of directed donation that is legal under federal law and under the laws of all 50 states. Parents can enroll their minor children. No one is excluded because of any medical condition.

[Arun Khanna]

"A legal non-monetary market for organs exists in the United States. It's called LifeSharers."
Every person on organ donation waiting list has strong incentives to join LifeSharers while healthy people have much weaker incentives to join this program.
I think Profesosr Becker's argument can be boiled down to organ donors motivated by altruism compared to organ donors motivated by altruism and organ donors motivated by monetary considerations. It's simple to show that the second alternative provides more organs than the first.

[Michael Meyers]

Markets are a good solution to this problem; however, exchanging money for organs is problematic as discussed. One suggestion that I've seen before, but not here, is that people who have "opted-in" for organ donation would go to the head of the line if they themselves, or their immediate family, needed an organ donation.

[nate]

It would be interesting to get an overview and explanation of the various types of people that need kidney and liver transplants. Perhaps some of this situation could be addressed though additional prevention measures or prevention incentives?

[amc]

It seems that this will increase the benefit of suicide attempts.

[jacob]

Markets are indeed a good solution for the problem. It'll decrease the waitings going on for a long period.

[Bob K]

A case study on the effect of a market for organs could be done in South America.

There, you can walk in and get any transplant you want if you have the cash.

But, there are indeed many kidnappings, and there is organ stealing even at hospitals. People walk in for an appendicitis surgery, wake up without a kidney.

There are also pregnant women who get killed for their unborn babies, to be sold at the adoption black market.

Yes, you could regulate that all organs have to prove their procedence, and so on, but then it would not be a real "free market".

I myself have no position on this topic as I might need a transplant some day, and traveling there is always an option. But it is disgusting to think the costs on so many innocent people this market imposes.

It is impossible to me to decide on the desirability of legalizing a market for organs without contemplating the moral dimension.

[Frank]

Hey guys! The NSA leak cries out for some erudition. LET"S GET ON IT!

[logicnazi]

The big question is who gets to opt-out.

My understanding is that in the states *even* if you have choosen to donate organs if a family member objects no organs are donated (I don't know what happens if you have a card but they can't find a family member). This is particularly problematic as it relies on family members making the deciscion at the point where they are least able to make a good judgement.

If these opt-out countries also allowed other family members to object after death I could understand why it might not get enough organs. However, my intuition is that if one had a system which required any person not wishing to donate their organs to register (say online or by mail) in advance I can't imagine their would be a current organ shortage.

Thinking briefly about the matter I'm inclined to oppose a true market in organs not because I'm squemish about offering people money for organs but because I don't think the shortage should be allowed in the first place. While a few people really believe organ donation interferes with their afterlife most people just feel a bit uncomfortable about it. Thus we have a situation where utility would be dramatically increased by demanding that everyone give up their organs. Basically (whatever it's history in common law http://www.yalelawjournal.org/archive_abstract.asp?id=310 ) I'm not a big fan of the right to destroy.

Pragmatically I think this would work best as a government tax credit for organ donation. If this is done in a revenue neutral fashion it effectively amounts to a fine for not donating one's organs. Thus only those people who *really* value not donating organs won't donate while we will still get enough organs for transplants. True, a fixed government tax break doesn't have the same flexibility of a freely floating market set price it also avoids many of the dangers of that route. More importantly though the ability of congress to raise other taxes to compensate prevents the 'payments' for organs from becoming a stealth 'tax' on the medical sector (transfering money from them to organ donars).

In short it seems clear that the utility gained from the benificery of a transplant/research body is greater than the utility lost by whatever percent of the population would have to donate. So I'm all for the government acting to put us in the higher utility state but if implemented as a payment it would risk draining funds from medicine rather than just detering people from not donating organs. Besides a tax break for organ donation (a non-revocable year long commitment) seems a lot more politically possible than payments for organ donation.

[logicnazi]

In my other post I suggested that a system of tax credits given to individuals making year long commitments to organ donation would be a better system. I wanted to add a few more words about that specifically in response to the points in your article.

First though let me point out that *any* system of compensation for organ donation is going to require a nationwide database for this purpose. The hospital needs to know right away whether or not they can harvest organs and even if family can be contacted how can they know this isn't expressly against the patients request. So as to avoid the severe anguish a person who believes he will not enter heaven because his family will donate his body for the money it needs to be possible for a person to say they don't want to donate. Therefore no matter what the system we need a nationwide databse where hospitals can look up someone's status as an organ donor.

Now a system where hospitals literally paid for organs would need to involve compensating hospitals when they were net donors of organs. Thus in this situation there is an incentive for illicit harvesting and for unscrupulous hospital employees to purchas organs from disreputable sources and divert the payment to themselves. I doubt it would be a big problem but by incentivising through personal tax breaks we completely avoid it. Since no one would have any inventive to produce organs, they would only be urged to commit to donating them on death, this also avoids the problem of rash deciscions.

So in short I think your argument shows that a market would be a better option than the current system but I don't think you showed that it is a better option than other types of incentivation (taxes).

Heck, if you want you could even rig a tax credit to avoid giving the poor the most inventive to donate and make it a percentage rebate. I can't understand why anyone would think this was a good idea but I think the whole idea of saying it is unfair to offer payment for something because the poor will take it seems absurd. The only way it could make sense is if you believe the poor are so stupid that when presented with these options they will make the wrong choice. If you believe the poor would *rationally* choose to donate organs for the money it isn't the payments for organs that are the problem but their initial economic circumstances. If it is rational to prefer money over organs that means the lack of money was a *worse* state than the lack of an organ.

[lincoln]

Niven's "Organlegger" stories were set in the near future,his stories about the State hundreds of years farther.I"m a liitle worried about the sale of organs,not because I worry about someone being kidnapped as a donor.(The purported donor and the organ could be easily HLA typed to make sure they're identical),but because of the reductio ad adsurbum a person's worth is their body parts.On the other hand ,I do believe lives would be saved and it's not more intrusive than having poor females serve as egg carriers.
Heinlein carried the sci-fi even farther in a novel tiitled(I believe),"I Shall Fear No Evil".This concerned an elderly multi-billionaire who needed a body for the first brain transplant.They put out signals for someone of a certain tissu: type.the murdered donor was his secretary. To summarize,this isn't like expecting only amateur athletes to compete in the Olympics.I think this is too objectivist.And how I hope Corey doesn't agree with me.

[Greg]

The lack of any moral or religious insight by Mr. Becker and most of the posters is laughable. Sale of organs (or children, or slaves) is not an issue that can or should be evaluated solely by free-market or individual utilitarian concepts.

The minimizing of exploitation of the poor is also troubling. Would poor people and rich people be equally likely to sell organs? Obviously the incentives are far different. Is it just that poor people will sell their organs, but be unable to afford transplants for themselves or their families?

[nate]

consider this article on obesity, diabetes, and transplants:

http://www.argusleader.com/apps/pbcs.dll/article?AID=/20060103/NEWS/601030306/1001

[Wes]

Whenever one group of people gets to make decisions for another group of people there is a high probability that the decision making group will have no objection to inflicting severe harm on the other group if the decision making group thinks that there might be even a slight benefit to themselves.If little old ladies were allowed to decide how airport security should treated young Muslim men then the Muslim men would most likely be subjected to horrific inspections (if they were allowed to travel at all). The solution to this problem is to subject little old ladies to the same searches that young Muslim men are subjected to even though little old ladies really aren't very dangerous in this respect.When it comes to organ sales, there is the problem that rich people are going to be buying the organs and poor people are going to be selling the organs and , in practice, it is the rich people who have the power to dictate the terms of the sale. The solution to this problem is the same as for airport screening: require randomly selected rich people to sell their organs to the government at the going rate and give these organs to randomly selected poor people who need organ transplants.Even though terrorism is way down the list of things that are likely to harm the average person, terrorism gets enough media attention that people think it it is very likely to harm them. Even if only a few rich people were required to sell their organs at the going rate, if it got enough media attention rich people would think it was very likely to happen to them and they would be careful to make sure that the terms of organ sales were fair.

[albatross]

I'm curious why organ sales creep so many people out. It seems clear to me that we could run it in such a way that kidnapping and organ theft essentially never happened (every donated organ carries an embedded, impossible-to-remove serial number in each cell). In the least objectionable version of the idea, you'd get paid something for agreeing to have your organs harvested at death--I just don't see how that would lead to exploitation of anyone. In a harder version of the idea to get accepted, anyone could sell a nonessential organ now. This means taking some personal risk and doing something unpleasant and maybe seriously painful for money. Maybe nobody's noticed, but there are plenty of people accepting that kind of transaction every day--the world's full of hard, unpleasant, and dangerous jobs.

I think one issue many people miss is that there's already lots of money in the organ transplant industry. The hospitals and doctors don't mind making money off every step of the transplant operation. It's just the donors that don't get paid. So if your concern is that the doctors will pull the plug on your respirator a little early so Bill Gates will get a fresher replacement kidney, that concern exists today, too. If your concern is that your worthless son in law will be trying to hawk your organs on e-bay while you're in the hospital with pneumonia, that's potentially creepy, but it sure seems like the sort of thing we can deal with within the law.

[Mr. Econotarian]

The belief that a market in organs would lead to "organ stealing" is as idiotic as believing that "organ stealing" would be done by patient relatives today under the non-compensated system. If I showed up at a hospital today with a liver in my bag, would they take my word for it and implant it in someone? (Keep in mind the hospital makes money from the operation alone.)

By ignoring basic economics, opponents of organ markets ARE KILLING PEOPLE TODAY who are going without needed organs.

I don't think that an organ market could exist without a level of regulation (just as today's non-compensated donor system requires regulation). It would have to ensure informed consent of the person selling their organ.

Regarding slavery, I consider it slavery that I am unable to sell something that belongs to me, namely my organs. Slavery is about lack of individual freedom. My liver is not an individual. I on the other hand am an individual.

Note that Egg Cell sales are legal today. They involve risks as well.